Healthcare Provider Details

I. General information

NPI: 1821133901
Provider Name (Legal Business Name): FORT WAYNE GI PATHOLOGY SERVICES, PC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD GI PATHOLOGY
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

6110 CONSTITUTION DR SUITE 112
FORT WAYNE IN
46804-1556
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7154
  • Fax: 260-435-7633
Mailing address:
  • Phone: 260-432-5867
  • Fax: 260-436-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number50004501A
License Number StateIN

VIII. Authorized Official

Name: MR. MAX L DANIELS
Title or Position: CORPORATE MANAGER
Credential:
Phone: 260-432-5867